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Results from an observational study show that the number of reported malaria cases in children and pregnant women on the Thai-Myanmar border has decreased significantly over the past decade.

However, the researchers found that resistance to 1st-line mefloquine-artesunate combination therapy has increased dramatically, with a significant increase in resistance observed in 2011.

"Alternative fixed combination treatments are needed urgently to replace the failing 1st-line regimen of mefloquine and artesunate," write the authors in PLoS Medicine. Francois Nosten (University of Oxford, UK) and colleagues analyzed observational data on malaria collected from the Thai-Myanmar border between October 1999 and September 2011, during which time the number of cross border health facilities increased from 2 to 11 and a focus on early diagnosis and treatment (EDT) was instituted.

The team assessed changes in the incidence and prevalence of malaria from a cohort of pregnant women and cross-sectional surveys. The number of visits to the health centers and their outcomes were also recorded. Nosten and co-investigators found that the number of health center visits for malaria decreased significantly in children under 5 years of age, from 78 percent in 1999 to 7 percent in 2011. Similarly, the incidence of malaria in pregnant women decreased from 1.1 to 0.1 episodes per pregnant-woman year from 1999 to 2011.

The researchers also found that the ratio of _Plasmodium falciparum_ to _Plasmodium vivax_ decreased from 1.4 to 0.7 over the study period and that the cumulative proportion of pregnant women infected with _P. falciparum_ during this time decreased from 24.3 percent to 3.4 percent.

Notably, the treatment efficacy of mefloquine-artesunate decreased significantly from a 0 percent slide-confirmed positivity for malaria at day 3 of treatment in 2000 to 28 percent slide positivity at 3 days in 2011. "Our results and results from elsewhere indicate that an aggressive strategy based on EDT of cases, combined with vector control and information to the population, is the way forward to eliminate malaria," write the authors.

They concede that "it is uncertain whether this strategy alone could achieve complete elimination over time," and acknowledge that the observational nature of their study limits the application of the results in the field. "Adjunctive approaches should be evaluated, such as the use of low-dose primaquine to reduce transmission further, mass drug administrations, more sensitive detection of sub-microscopic infections using molecular methods, or targeted use of the new malaria vaccine, if it is approved," they suggest.

Communicated by: ProMED-mail

[It is indeed worrisome that resistance to the artemisinin group of antimalarial drugs is emerging at the Thai-Myanmar border region. It was the same area which saw the development of resistance to chloroquine, sulfadoxine/pyrimethamine, and mefloquine.)

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About SASTM

The SASTM’s Mission is to guide the profession in all aspects relating to the practice of travel medicine,
liaise with the travel industry, consult with relevant authorities,
advise the public and collaborate nationally and internationally on all aspects relating to Travel Medicine.

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